688
Management of outpatients
BRITISH MEDICAL JOURNAL
10 MARCH 1979
know that there are probably many nurses in contractual arrangements; but the nature of the United Kingdom who have functioned consultant responsibility is different from that SIR,-Two patients of our practice have safely as nurse practitioners in northern of any other hospital doctor and such responattended the outpatient departments of Canada and who are at present being under- sibility cannot be discharged on the basis of a different teaching hospitals for many years used in hospitals or district nursing positions. closely defined contractual unit. (seven years in one case and 14 in the other). DAVID BOLT Chairman, Negotiating Subcommittee, CCHMS During that time they have not seen the BARBARA J EDGECOMBE-GREEN London WC1 consultant in charge of the clinic and the Edmonton, hospital letters have come from a series of Alberta, Canada registrars. Furthermore, the contents of the letters suggest that the patients have not State of community medicine been subject to recurrent full assessment but What price the new consultant contract? SIR,-After reading the two reports (17 have been treated for their current symptoms. They have not been considered for discharge. SIR,-Mr T MacFarlane (20 January, p 208) February, p 503) concerning the future Many hospital consultants occasionally wrote a thoughtful article on the new contract training of community health doctors it is review the longstanding outpatients in their for consultants, expressing reservations about difficult to escape the impression that some care, but this perhaps should be more clearly some aspects of the agreement reached between obsolete patterns of the past are still being defined in the job specification of the role of CCHMS and Government. In particular, he used as blueprints for the future. Perhaps, the consultant in outpatients. There should expressed concern about the lack, in any of the like the Court Committee' before them, be an introduction of training for junior relevant documents, of a definition of the members of both working parties embraced medical staff in this management function. notional half day. I felt that I should comment the philosophy of modern doctoring too on this particular issue, as it is fundamental to warmly to allow them to raise their sights R LAW the concepts on which the new contract is beyond the immediate and middle future to London NW1O the distant future of community child care based. When the profession agreed to explore the training. Today doctors are becoming trained as possibility of fundamental change in the terms Extending the role of the clinical nurse under which consultants were employed in the technologists of increasing sophistication and National Health Service, it made clear to its taught to be decisive in their quest for correct SIR,-I read with interest your leading article negotiators that any contract which was answers to disease, because this is what "Extending the role of the clinical nurse" developed must continue to be appropriate to modern society demands of them. The (11 November, p 1320 (Community health. professional people and that it must not be community paediatrician however has no nurses have been safely acting as primary such as to encourage "clock-watching" atti- ready answers, and must therefore patiently purveyors of health care in Canada's north for tudes, much less clocking in and clocking out. learn to recognise the interplay between many years. For this reason, the unit which was chosen as physical, emotional, and social factors before The northern nurse practitioner is employed a basis for the new contract was the notional attempting much in the way of specific answers by the Canadian Department of Health and half day, defined as at present, in paragraph to community clinical problems. Welfare and is in a position of respondeat 61 of the terms and conditions of service If community child care training is to superior, deemed to be working under the (which is included unchanged in appendix 2 develop logically then surely some fundadirection of a physician. These nurses are to the contract offer). mental changes should occur in undergraduate employed in nursing stations across Canada's Throughout negotiations it was accepted on preclinical thinking, allowing psychology, north, often hundreds of miles from the both sides that the nature of consultant work anthropology, and medical sociology to carry nearest doctor. All nurses have access to did not lend itself to the use of a tightly a status in our medical schools equal to that of consultation with a physician by telephone or defined unit and that the right of the consultant chemistry, physics, and anatomy. Were this radio and physicians visit the isolated settle- to adjust his precise time schedule from day to elementary change to be implemented ments on varying schedules of regularity. day as pressure of work demanded was as immediately it would still take about 10 years The nurse may refer patients to a physician important to the successful operation of the for the first batch of suitably trained in an emergency or for follow-up by a physician Health Service as it was to the feeling of pro- community paediatricians to emerge as the within the settlement if it is deemed necessary. fessional independence enjoyed by the consult- new kind of doctors needed to cope with the Much of the regular general practitioner work ant. Over the 30 years that the NHS has challenge posed by current clinical community load is carried out by these nurses, including existed, the present very general definition of paediatrics. such tasks as history taking, diagnosis, the notional half day has come to be well PETER J RAWLINSON prescription, dispensing of medications, x- understood by consultants and health authoriGWYNNE V LEWIS raying of chest and limbs, and suturing. ties. To have renegotiated the definition must Health Department, Emergency care of patients may include have created greater precision and a more Ipswich, Suffolk 1 Committee on Child Health Services, Fit for the intravenous therapy and cardiopulmonary restrictive interpretation by both sides. Future, London, HMSO, 1976. resuscitation. Prenatal and postnatal care and When I have spoken on this subject, both to the delivery of uncomplicated obstetric CCHMS and to meetings of consultants round patients (gravida 2-4,) are also the responsibility the country, I have frequently used the expresof the nurses. Besides carrying out regular sion "flexibly worked" to explain my under- Consultant milage allowances treatment at clinics the nurse practitioner is standing of the notional half day in both the also responsible for the public health service in present and the new contract. The source of SIR,-May I be permitted through your her area. this phrase, which sums up the position column to add one further experience of the Training for clinical nurses is at present admirably, was a letter to the profession, DHSS's attitude to travelling expenses for offered in a four-month course at the written on behalf of the previous secretary of consultants using their own cars in the pursuUniversity of Alberta, but unfortunately it is state in 1975. I have often gone on to illus- ance of their professional commitments ? As a result of the reorganisation of the child not possible for all nurses employed by medical rate the point by remarking that one of my own services to attend such courses. Those unable NHDs can usually be completed in 21 hours and adolescent psychiatric service in the to attend find that previous nursing experience but that on the day of my principal operating district my headquarters were moved some 11 stands them in good stead and enables them session one NHD commonly lasts for 4- hours miles. The bulk of my clinical work is domito function adequately if working alongside or even longer, this being the nature of the ciliary based (without payment of a domiciliary more experienced nurse practitioners. NHD, worked flexibly. The continued use of fee) and community orientated, which has I agree that a nurse is not a physician the existing definition of a notional half day allowed closure of the children's hospital in the substitute but with experience and, preferably, will allow this type of arrangement to continue district. I now find that a considerable amount additional training she may become a valuable after the introduction of the new contract. of my milage (some 4800 miles (7700 km) per asset for a busy practice. At a time when Indeed, it is difficult to see how the Health year) which was previously paid at official rate health costs are increasing exponentially I Service could be operated on any other basis. is now paid at excess travelling expenses rate, submit that a nurse practitioner orientated I have every sympathy with my colleagues even though this milage would have been towards health teaching cannot but be in the training grades who, because of prob- driven under the original arrangement and lems in the past, feel that a very precise therefore attracted the official milage rate. The advantageous. It may be of interest to your readers to definition is necessary as a basis for their Department is therefore able to save the pay-
Management of outpatients
BRITISH MEDICAL JOURNAL
10 MARCH 1979
know that there are probably many nurses in contractual arrangements; but the nature of the United Kingdom who have functioned consultant responsibility is different from that SIR,-Two patients of our practice have safely as nurse practitioners in northern of any other hospital doctor and such responattended the outpatient departments of Canada and who are at present being under- sibility cannot be discharged on the basis of a different teaching hospitals for many years used in hospitals or district nursing positions. closely defined contractual unit. (seven years in one case and 14 in the other). DAVID BOLT Chairman, Negotiating Subcommittee, CCHMS During that time they have not seen the BARBARA J EDGECOMBE-GREEN London WC1 consultant in charge of the clinic and the Edmonton, hospital letters have come from a series of Alberta, Canada registrars. Furthermore, the contents of the letters suggest that the patients have not State of community medicine been subject to recurrent full assessment but What price the new consultant contract? SIR,-After reading the two reports (17 have been treated for their current symptoms. They have not been considered for discharge. SIR,-Mr T MacFarlane (20 January, p 208) February, p 503) concerning the future Many hospital consultants occasionally wrote a thoughtful article on the new contract training of community health doctors it is review the longstanding outpatients in their for consultants, expressing reservations about difficult to escape the impression that some care, but this perhaps should be more clearly some aspects of the agreement reached between obsolete patterns of the past are still being defined in the job specification of the role of CCHMS and Government. In particular, he used as blueprints for the future. Perhaps, the consultant in outpatients. There should expressed concern about the lack, in any of the like the Court Committee' before them, be an introduction of training for junior relevant documents, of a definition of the members of both working parties embraced medical staff in this management function. notional half day. I felt that I should comment the philosophy of modern doctoring too on this particular issue, as it is fundamental to warmly to allow them to raise their sights R LAW the concepts on which the new contract is beyond the immediate and middle future to London NW1O the distant future of community child care based. When the profession agreed to explore the training. Today doctors are becoming trained as possibility of fundamental change in the terms Extending the role of the clinical nurse under which consultants were employed in the technologists of increasing sophistication and National Health Service, it made clear to its taught to be decisive in their quest for correct SIR,-I read with interest your leading article negotiators that any contract which was answers to disease, because this is what "Extending the role of the clinical nurse" developed must continue to be appropriate to modern society demands of them. The (11 November, p 1320 (Community health. professional people and that it must not be community paediatrician however has no nurses have been safely acting as primary such as to encourage "clock-watching" atti- ready answers, and must therefore patiently purveyors of health care in Canada's north for tudes, much less clocking in and clocking out. learn to recognise the interplay between many years. For this reason, the unit which was chosen as physical, emotional, and social factors before The northern nurse practitioner is employed a basis for the new contract was the notional attempting much in the way of specific answers by the Canadian Department of Health and half day, defined as at present, in paragraph to community clinical problems. Welfare and is in a position of respondeat 61 of the terms and conditions of service If community child care training is to superior, deemed to be working under the (which is included unchanged in appendix 2 develop logically then surely some fundadirection of a physician. These nurses are to the contract offer). mental changes should occur in undergraduate employed in nursing stations across Canada's Throughout negotiations it was accepted on preclinical thinking, allowing psychology, north, often hundreds of miles from the both sides that the nature of consultant work anthropology, and medical sociology to carry nearest doctor. All nurses have access to did not lend itself to the use of a tightly a status in our medical schools equal to that of consultation with a physician by telephone or defined unit and that the right of the consultant chemistry, physics, and anatomy. Were this radio and physicians visit the isolated settle- to adjust his precise time schedule from day to elementary change to be implemented ments on varying schedules of regularity. day as pressure of work demanded was as immediately it would still take about 10 years The nurse may refer patients to a physician important to the successful operation of the for the first batch of suitably trained in an emergency or for follow-up by a physician Health Service as it was to the feeling of pro- community paediatricians to emerge as the within the settlement if it is deemed necessary. fessional independence enjoyed by the consult- new kind of doctors needed to cope with the Much of the regular general practitioner work ant. Over the 30 years that the NHS has challenge posed by current clinical community load is carried out by these nurses, including existed, the present very general definition of paediatrics. such tasks as history taking, diagnosis, the notional half day has come to be well PETER J RAWLINSON prescription, dispensing of medications, x- understood by consultants and health authoriGWYNNE V LEWIS raying of chest and limbs, and suturing. ties. To have renegotiated the definition must Health Department, Emergency care of patients may include have created greater precision and a more Ipswich, Suffolk 1 Committee on Child Health Services, Fit for the intravenous therapy and cardiopulmonary restrictive interpretation by both sides. Future, London, HMSO, 1976. resuscitation. Prenatal and postnatal care and When I have spoken on this subject, both to the delivery of uncomplicated obstetric CCHMS and to meetings of consultants round patients (gravida 2-4,) are also the responsibility the country, I have frequently used the expresof the nurses. Besides carrying out regular sion "flexibly worked" to explain my under- Consultant milage allowances treatment at clinics the nurse practitioner is standing of the notional half day in both the also responsible for the public health service in present and the new contract. The source of SIR,-May I be permitted through your her area. this phrase, which sums up the position column to add one further experience of the Training for clinical nurses is at present admirably, was a letter to the profession, DHSS's attitude to travelling expenses for offered in a four-month course at the written on behalf of the previous secretary of consultants using their own cars in the pursuUniversity of Alberta, but unfortunately it is state in 1975. I have often gone on to illus- ance of their professional commitments ? As a result of the reorganisation of the child not possible for all nurses employed by medical rate the point by remarking that one of my own services to attend such courses. Those unable NHDs can usually be completed in 21 hours and adolescent psychiatric service in the to attend find that previous nursing experience but that on the day of my principal operating district my headquarters were moved some 11 stands them in good stead and enables them session one NHD commonly lasts for 4- hours miles. The bulk of my clinical work is domito function adequately if working alongside or even longer, this being the nature of the ciliary based (without payment of a domiciliary more experienced nurse practitioners. NHD, worked flexibly. The continued use of fee) and community orientated, which has I agree that a nurse is not a physician the existing definition of a notional half day allowed closure of the children's hospital in the substitute but with experience and, preferably, will allow this type of arrangement to continue district. I now find that a considerable amount additional training she may become a valuable after the introduction of the new contract. of my milage (some 4800 miles (7700 km) per asset for a busy practice. At a time when Indeed, it is difficult to see how the Health year) which was previously paid at official rate health costs are increasing exponentially I Service could be operated on any other basis. is now paid at excess travelling expenses rate, submit that a nurse practitioner orientated I have every sympathy with my colleagues even though this milage would have been towards health teaching cannot but be in the training grades who, because of prob- driven under the original arrangement and lems in the past, feel that a very precise therefore attracted the official milage rate. The advantageous. It may be of interest to your readers to definition is necessary as a basis for their Department is therefore able to save the pay-
